Acute Decompensated Heart Failure

Question 1

HF

What are the pharmacologic recommendations for patients at risk for HF?

Answer 1

• pt with HTN= control BP
• pt with T2DM and w/ CVD or at high risk for CVD= SGLT2i
• pt with CVD= optimal management of CVD

Question 2

HF

What are the pharmacologic recommendations for patients with pre-HF (Stage B)?

Answer 2

pt with LVEF 40% or less= ACEi or ARB is ACEi intolerant and beta blocker

Question 3

HF

What is initial pharmacologic treatment for HFrEF stage C/D?

Answer 3

• ARNi or ACEi/ARB
• beta blocker
• mineralcorticoid receptor antagonist (MRA)
• SGLT2i
• diuretics PRN

Question 4

HF

Define: Acute Decompensated HF

Answer 4

worsening of heart failure requiring hospitalization

Question 4

HF

What are the precipitating factors of HF?

Answer 4

• acute coronary syndrome (ACS)
• uncontrolled HTN
• atrial fibrillation (arrhythmias)
• dietary or medication non-adherence
• anemias
• acute infections
• hyper/hypo-thyroidism
• harmful medication use

Question 5

HF

What medications contribute to fluid overload?

Answer 5

• NSAIDs
• COX-2 inhibitors
• glucocorticoids
• minoxidil
• TZDs

Question 6

HF

What medications contribute to decreased perfusion?

Answer 6

• new or high doses of anti-hypertensives
• excessive diuretic use

Question 7

HF

What medications can worsen HF due to negative inotrope properties?

Answer 7

• antiarrhythmics
• non-DHP calcium channel blockers (verapamil and diltiazem)

Question 8

HF

How may a patient present with ADHF with congestion/fluid overload?

Answer 8

• edema
• dyspnea
• orthopnea
• elevated jugular venous pressure
• pulmonary rales/crackles
• S3 gallop

Question 9

HF

How may a patient present with ADHF with low perfusion?

Answer 9

• narrow pulse pressure
• cool extremeties
• hypotension
• tachycardia

Question 10

HF

What laboratory values/diagnostic test can assist in identifying ADHF?

Answer 10

• BNP or NT-proBNP!!!
• serum sodium
• LFT
• urine output
• BUN/serum creatinine
• chest xray
• TTE

Question 11

HF

What device can allow for more objective fluid overload status?

Answer 11

flow-directed pulmonary artery catheter (Swan-Ganz catheter)

Question 12

HF

What does a pulmonary capillary wedge pressure > 18 mmHg indicate?

Answer 12

congestion/fluid overload

Question 13

HF

What does a reduced cardiac index of < 2.2 L/min/m2 indicate?

Answer 13

low cardiac output/low perfusion

Question 14

HF

What does “warm” mean?

Answer 14

low perfusion NOT observed= cardiac index normal

Question 15

HF

What does “cold” mean?

Answer 15

low perfusion= cardiac index <2.2 L/min/m2, signs/symptoms include narrow pulse pressure, cool extremeties, hypotension

Question 16

HF

What does “dry” mean?

Answer 16

congestion at rest not present= capillary wedge pressure normal

Question 17

HF

What does “wet” mean?

Answer 17

congestion at rest= capillary wedge pressure > 18 mmHg, signs/symptoms include orthopnea, elevated jugular venous, pulmonary rales, S3 gallop, edema, dyspnea

Question 18

HF

What drugs may be used to treat fluid overload?

Answer 18

• loop diuretics
• thiazide diuretics
• venodilators (nitroglycerin/nitroprusside)

Question 19

HF

What drugs may be used to treat low cardiac output?

Answer 19

• positive inotropes (dobutamine/milrinone)
• arterial vasodialators (nitroprusside)

Question 20

HF

What is the initial pharmacologic management for congestion/fluid overload?

Answer 20

IV loop diuretics

Question 21

HF

What are the preferred loop diuretics for decongestion?

Answer 21

furosemide, bumetanide, torsemide(not avaliable IV)

Question 22

HF

What is the goal response with loop diuretics?

Answer 22

> 500 mL urine output within 2 hours

Question 23

HF

What is the recommended dosing for loop diuretics for decongestion?

Answer 23

intermittent or continuous IV at equal or greater dose of the patients daily chronic dose

Question 24

# HF What are the monitoring parameters while on loop diuretics?

Answer 24

- fluid intake and output - vital signs - body weight - electrolytes, BUN, SCr

Question 25

# HF How can "diuretic resistance" be overcome?

Answer 25

- higher doses of loops - addition of second diuretic - ultrafiltration - low-does dobutamine - vasopressin antagonist - vasodilators

Question 26

# HF What is the role of thiazide diuretics in ADHF?

Answer 26

may be used for congestion when loops are inadequate, adjunct therapy, close monitoring required

Question 27

# HF What is the role of vasodilators for ADHF?

Answer 27

add on therapy for refractory congestion, hypotension must not be present

Question 28

# HF What vasodilators may be used for congestion?

Answer 28

- nitroglycerin (venodilator) - sodium nitropusside (venodialator + arterial vasodilator)

Question 29

# HF What patients are ideal for nitroglycerin use in congestion?

Answer 29

pt with hypertension, coronary ischemia or significant mitral regurgitation

Question 30

# HF What are the warnings/precautions associated with nitroglycerin?

Answer 30

- tachyphylaxis - hypotension - elevated intracranial pressure

Question 31

# HF What patients are ideal for sodium nitroprusside use in congestion?

Answer 31

severe congestion with hypertension or severe mitral valve regurgitation

Question 32

# HF What are the warnings/precautions associated with sodium nitroprusside?

Answer 32

- requires invasive BP monitoring!!! - renal insufficiency - rebound phenomenon - elevated intracranial pressure

Question 33

# HF What is the recommendation for using inotropes for low perfusion?

Answer 33

not to be used long-term, but can be used in patients with cardiogenic shock as a bridge therapy

Question 34

# HF What drugs are inotropes that may potentially be used for low perfusion?

Answer 34

dobutamine and milirone

Question 35

# HF What is the mechanism of dobutamine?

Answer 35

adrenergic agonist, primarly beta1and beta2, some alpha1

Question 36

# HF What is the mechanism of milrinone?

Answer 36

vasodilator via PDE inhibition

Question 37

# HF What are the adverse effects of dobutamine?

Answer 37

- tachyarrhythmias - BP instability - headache - nausea - fever

Question 38

# HF What are the adverse effects of milrinone?

Answer 38

- arrhythmias - hypotension - thrombocytopenia

Question 39

# HF What are the monitoring parameters for patients with ADHF?

Answer 39

- daily weights - I/O - electrolytes (Na+/K+/Ca2+/Mg2+) - SCr/BUN - vital signs - physical exam - BNP, NT-proBNP